What’s the Best Treatment for Obsessive-Compulsive Disorder?

.Summary: The best treatment for obsessive-compulsive disorder may include psychotherapy, gradual exposure, medication, and brain stimulation technologies.

Key Points:

• Obsessive-compulsive disorder (OCD) is an anxiety disorder that can lead to severe disruption and impairment in daily life.
• OCD can develop in any person, regardless of demographic or cultural background and characteristics.
• Evidence-based treatment administered by experienced mental health professionals can help people with OCD can learn to manage their symptoms and lead a full and productive life.

What is Obsessive-Compulsive Disorder?

Experts on OCD define the disorder as follows:

“OCD is a mental health disorder that affects people of all ages and walks of life, and occurs when a person gets caught in a cycle of obsessions and compulsions. Obsessions are unwanted, intrusive thoughts, images, or urges that trigger intensely distressing feelings. Compulsions are behaviors an individual engages in to attempt to get rid of obsessions and/or decrease distress.”

That’s a good way to understand OCD. It’s a type of mental health disorder involving unwanted and repetitive thoughts and behaviors that can significantly impair the ability to function in daily life.

The National Institutes of Health (NIH) report the following prevalence of OCD among adults in the U.S.:

Diagnosis of OCD in previous 12 months:

• Total: 1.2%
  • Females: 1.8%
  • Males: 0.4%

That’s just over 3 million people.

Diagnosis of OCD at any point:

• Total, adults 18+: 2.3%

That’s about 6 million people.

Severity of OCD among people diagnosed with OCD:

• Mild: 15%
• Moderate: 35%
• Severe: 51%

Those figures show us that millions of adults in the U.S. have OCD. For these people, finding effective, evidence-based treatment can be life changing. Consider the fact that without treatment, the consequences of OCD may include:

• Isolation/withdrawal from friends and loved ones
• Relationship problems
• Academic problems
• Work problems
• Alcohol/drug use
• Suicidal ideation
• Non-suicidal self-injury (NSSI)

Evidence shows OCD often co-occurs with other mental health and/or addiction disorders:

• Separate mental health diagnosis+ OCD: 90%
• Separate anxiety disorder + OCD +: 76%
• Mood disorder + OCD: 65%
• Attention disorder + OCD: 56%
• Addiction disorder/substance use disorder + OCD: 40%

Those facts show us that the consequences of untreated OCD can be serious, and that treatment for OCD is often complicated by the presence of co-occurring disorders. Before we review the best treatment for OCD, let’s learn more about the symptoms of OCD, which should explain why they can be so disruptive.

The Signs and Symptoms of Obsessive-Compulsive Disorder (OCD): Obsessions and Compulsions

In clinical OCD, mental health professionals define obsessions as follows:

“Obsessions in OCD are thoughts, images, or impulses that occur over and over again and feel outside of the person’s control.”

People with OCD may develop obsessions about a wide variety of things, but most develop obsessions about specific categories of things, behaviors, and feelings.

Common Obsessions Among People With OCD

People with OCD often develop obsessions about contamination. These obsessions include, but are not limited to:

• Germs
• Dirt
• Chemicals
• Bodily fluids

While violent behavior is not a characteristic or symptom of OCD, some, but not all, people with OCD develop an obsession with violence, violent thoughts, and violent behavior. They may experience recurring, obsessive thoughts related to violence, such as:

• Extreme concern they may hurt themselves somehow
• Extreme concern they may hurt other people somehow
• Escalating worry about experiencing violent thoughts

People with OCD often develop obsessions around the idea or concept of responsibility. Obsessive thoughts related to responsibility may include:

• Fear that a lapse in responsibility may cause harm to another person
• Fear they’ll harm another person by accident

People with OCD often develop obsessions around the idea or concept of perfectionism. Common obsessions associated with perfectionism include, but are not limited to:

• Personal possessions: constantly organizing and reorganizing
• Home/items in the house: constantly organizing and reorganizing
• Need to know all facts about a topic
• Need to share with others they know all facts about a topic
• Excess worry about losing track of personal possessions
• Preoccupation with doing everything exactly right
• Excess worry about any type of mistake at all

Those lists above are incomplete, because people with OCD may develop obsessions about virtually anything. In addition to the obsessions above, people with OCD may develop obsessions about death, sex, religion, and relationships, morality, religion, sex, and death, to name a few.

Next, we’ll shift our focus to compulsions. In the context of OCD, mental heath experts define compulsions as follows:

“Compulsions are repetitive behaviors or thoughts that a person uses with the intention of neutralizing, counteracting, or making their obsessions go away.’

Let’s take a moment to review the most common compulsions associated with OCD.

Common Compulsions Among People With OCD

People with OCD often develop compulsions related to cleaning and washing things. These compulsions may include, but are not limited to:

• Washing hands in one predetermined way only, every time
• All aspects of individual grooming and personal hygiene
• Constantly attending to things around the home, related to organizing and cleaning
• Repetitive behaviors related to avoiding things that are unclean/unorganized

People with OCD often develop compulsions associated with checking on things. These compulsions may include, but are not limited to:

• Making their behavior doesn’t hurt anyone
• Making sure they don’t hurt themselves
• Concern about others getting hurt, especially family and friends
• Making sure they don’t ever make even the smallest mistake

People with OCD often develop compulsions associated with repeating things. These compulsions may include, but are not limited to:

• Sitting down and standing up, turning lights on and off, turning appliances on and off, repetitively closing/opening cabinets, doors, windows, etc.
• Behavioral habits and/or movements, including scratching/itching, touching things for luck, other repetitive behaviors like foot/finger tapping, blinking eyes, wringing hands, etc.
• Engaging in specific types of behavior in specific numbered patterns only, such as always shutting the bathroom door five times, stirring a cup of coffee 20 times every time, or turning off the porch light three times every time.

People with OCD engage in compulsive behaviors for a variety of reasons, but most say they engage in them to correct, fix, or make things look and feel right to them. They arrange objects until they feel satisfied, count objects until they arrive at the right number, repeat actions until they feel they’ve performed them perfectly, in order to nullify what they believe will be the negative consequences of performing them imperfectly.

With all that in mind, let’s review what we know about the best available treatments for obsessive-compulsive disorder.

The Best Treatment for Obsessive-Compulsive Disorder: Comprehensive and Integrated

A new State of the Art review and meta-analysis of the current best treatment for obsessive-compulsive disorder published by the British Medical Journal (BMJ) called “Management of Obsessive-Compulsive Disorder in Adults” confirms the best practices in OCD treatment include psychotherapy, medication, and brain stimulation/neuromodulation techniques. The exact combination of these approaches depend on the specific presentation of the disorder for each individual.

The best modes of psychotherapy for OCD include:

• Cognitive behavioral therapy (CBT)
• Exposure Response Therapy (ERP)
• Eye-Movement Desensitization and Response (EMDR)
• Acceptance and commitment therapy (ACT)

The best medications for OCD include:

• Antidepressants:
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Tricyclic antidepressants (TCAs)
• New medications:
  • IV ketamine
  • Oral esketamine
• Emerging medications, currently under research:
  • Psilocybin
  • MDMA

Brain stimulation therapies, also called neuromodulation therapies, may include:

• Transcranial magnetic stimulation (TMS)
• Deep brain stimulation

Those treatments can all help people with OCD. But what is the treatment process like?

How Treatment for OCD Typically Works: The Diagnosis and Treatment Process

The authors of the State of the Art review that we introduce above outline a clear, five-step process that outlines how an individual can receive the best treatment for obsessive-compulsive disorder (OCD). In ideal circumstances, here’s how the process of finding the best treatment for obsessive-compulsive disorder can work:

Step 1: Diagnosis

After a complete biopsychosocial assessment, a qualified provider diagnoses OCD, identifies severity, and refers patient for evidence-based treatment.

Step 2: Treatment Planning and Treatment

Patient and provider establish a positive therapeutic alliance, discuss treatment goals and preferences, decide on a treatment plan, and initiate first-line treatments, including:

• Psychotherapy:
  • Exposure Response Therapy (ERP)
• Medication:
  • SSRIs
• Combined medication/psychotherapy

Step 3: Observation and Adjustment

If first-line treatment fails to meet goals established by patient and provider, the provider may consider recommending second-line therapies, such as:

• Psychotherapy:
  • Cognitive behavioral therapy (CBT)
  • Acceptance and commitment therapy (ACT)
• Medication:
  • Alternative SSRIs
  • SNRIs (selective norepinephrine reuptake inhibitors)
  • Atypical anti-psychotic medication
• Complementary modes:
  • Mindfulness
  • Skill from dialectical behavior therapy (DBT)

Step 4: Ongoing Observation and Adjustment

If first- and second-line treatments fail to meet goals established by patient and provider, the provider may consider recommending third-line therapies, such as:

• Transcranial magnetic stimulation (TMS)
• Deep brain stimulation

Step 5: New Medication for Treatment Resistant OCD

If the first-, second-, and third-line treatments fail to meet treatment goals, patient and provider may discuss emerging therapies for OCD, including:

• Ketamine
• Spravato®
• Psilocybin
• MDMA

Please keep in mind that the process we describe reflects the most advanced and most reliable knowledge we have about treating OCD. While it may be tempting for some patients to skip the first-line treatments in favor of new and emerging treatments, it’s important to follow the advice of mental health professionals and initiate the treatment process with three essential things:

1. An open mind
2. Trust in the treatment team and process
3. Hope and belief that healing is possible

People with OCD, whether mild, moderate, or severe, can and do learn to manage their symptoms and live a full, productive, and fulfilling lives. If you or someone you know has OCD and needs treatment, please remind them that the earlier they receive evidence-based treatment for a clinical mental health disorder, the better the outcome.